Wastewater surveillance for rapid identification of infectious diseases in prisons
Authors: Francis Hassard, Theodore R Smith, Alexandria B Boehm, Shannon Nolan, Oscar O'Mara, Mariachiara Di Cesare, David Graham
Journal: The Lancet Microbe (2022)

COVID-19 remains one of the biggest global public health challenges, accounting for more than 6·2 million deaths since the beginning of the pandemic. Alternative tools for rapidly identifying, containing, and reducing the spread of SARS-CoV-2, the virus that causes COVID-19, are crucial for susceptible populations. Examples include individuals living in prisons, care homes, and hospitals, among whom infection rates and mortality are often elevated compared with the general population.1Hassard F Lundy L Singer AC Jasmine G Di Cesare M Innovation in wastewater near-source tracking for rapid identification of COVID-19 in schools.Lancet Microbe. 2020; 2: e4-e5Summary Full Text Full Text PDF PubMed Scopus (27) Google ScholarPrison facilities including general prisons, juvenile detention centres, immigration detention centres, and community-rehabilitation centres represent particularly high-risk settings because individuals who are incarcerated reside in confined, densely populated, closed, and poorly ventilated conditions. In 2020, The Lancet reported that prisons "are in no way equipped to deal with COVID-19"2Burki T Prisons are "in no way equipped" to deal with COVID-19.Lancet. 2020; 395: 1411-1412Summary Full Text Full Text PDF PubMed Google Scholar and infection burdens in such settings are unknown due to paucity of testing. In the USA, more than 2700 COVID-19-related deaths have occurred in prison settings, with a mortality rate of around 200 prisoners per 100 000 population (April, 2020, to April, 2021),3Marquez N Ward JA Parish K Saloner B Dolovich S COVID-19 incidence and mortality in federal and state prisons compared with the US population, April 5, 2020, to April 3, 2021.JAMA. 2021; 326: 1865-1867Crossref PubMed Scopus (17) Google Scholar resulting in COVID-19 mortality rates 2·4–3·0-times higher than the general population.4Braithwaite I Edge C Lewer D Indirect age-and sex-standardisation of COVID-19-related mortality rates for the prison population of England and Wales.https://discovery.ucl.ac.uk/id/eprint/10123265/1/Covid19_and_prisons_SMRs.pdfDate: March 8, 2021Date accessed: May 24, 2022Google ScholarHigh prevalence and transmissibility of disease agents in prisons is also associated with the elevated risk profiles among individuals in the criminal justice system, such as complex medical and lifestyle histories (age, sedentary lifestyle, asthma, and obesity), high prevalence of multimorbidity, and various life-threatening conditions. Such problems are highest in prisons in low-income and middle-income settings due to substantial overcrowding, inadequate food and water availability, poor ventilation, and poor sanitation, all of which exacerbate transmission of infectious diseases between individuals living in prison. Prisons are also connected to communities (and other prisons) through prison staff and residents being infected in the community and through prisoner transfers to other facilities. In addition, infections can spread through prisoner day release, during prison receptions, and during medical care. More studies are needed to ascertain whether prisons can act as amplifiers of, or reservoirs for, COVID-19 and other infectious diseases5Barnert E Ahalt C Williams B Prisons: amplifiers of the COVID-19 pandemic hiding in plain sight.Am J Public Health. 2020; 110: 964-966Crossref PubMed Scopus (18) Google Scholar and whether prisons represent points at which interventions could be implemented to prevent wider transmission. We contend that inadequate action on managing prison health will result in further outbreaks of COVID-19 and other emerging infectious diseases that affect the health and wellbeing of staff, residents, and local populations.Wastewater-based surveillance has been widely applied during the COVID-19 pandemic as an unbiased, aggregate and anonymous method of monitoring for population-level infection trends and the spread of variants,6Wade MJ Lo Jacomo A Armenise E et al.Understanding and managing uncertainty and variability for wastewater monitoring beyond the pandemic: lessons learned from the United Kingdom national COVID-19 surveillance programmes.J Hazard Mater. 2022; 424127456Crossref PubMed Scopus (32) Google Scholar but it should not replace clinical testing for infectious diseases. Despite ethical concerns, wastewater-based surveillance of prisons has been used in numerous countries for surveillance of self-administered prescription and recreational drugs.7Postigo C de Alda ML Barceló D Evaluation of drugs of abuse use and trends in a prison through wastewater analysis.Environ Int. 2011; 37: 49-55Crossref PubMed Scopus (118) Google Scholar Our experience of wastewater-based surveillance across spatial scales (from sewershed to building to sub-building level) has enabled early identification of local outbreaks and informed targeting for rapid clinical testing, to reduce the disease burden and prevent further infections.8Alexander TY Hughes B Wolfe MK et al.Estimating relative abundance of 2 SARS-CoV-2 variants through wastewater surveillance at 2 large metropolitan sites, United States.Emerg Infect Dis. 2022; 28: 940Crossref PubMed Scopus (4) Google ScholarThree key barriers remain to fully realise the benefits of wastewater-based surveillance technology: first, paucity of data on virus faecal shedding between individuals makes it difficult to scale pathogen load to cases, and the impact of vaccines and disease variants on virus shedding warrants further research; second, determining the scope of the contributing population (eg, defecation frequency and movement of individuals between and within sewer catchments); and, third, dilution from other water sources, such as industrial scale laundries, reducing infectious disease marker signals. Prisons are unique, since residents in most prisons contribute regularly to the same wastewater stream (with the exception of day release prisoners and staff) and, therefore, provide a representative indicator of cases, such as COVID-19, when paired with clinical surveillance data.Prisons present several challenges for implementation of wastewater-based surveillance. First, access to wastewater is restricted for most research groups and prison infrastructure (eg, sewer pipes) can make installation of sampling equipment difficult. Second, individuals who live in prisons represent a marginalised population, and a strict ethical code is required for research work,9Hrudey SE Silva DS Shelley J et al.Ethics guidance for environmental scientists engaged in surveillance of wastewater for SARS-CoV-2.Environ Sci Technol. 2021; 55: 8484-8491Crossref PubMed Scopus (14) Google Scholar thus ethical review board oversight is crucial. Third, the minimum size of the population that can and should be monitored is unknown. Fourth, the nature of prisons makes their wastewater variable and some common chemical markers (eg, ammonia)10Hoar C Li Y Silverman AI Assessment of commonly measured wastewater parameters to estimate sewershed populations for use in wastewater-based epidemiology: insights into population dynamics in New York City during the COVID-19 Pandemic.ACS EST Water. 2022; (published online April 20.)https://doi.org/10.1021/acsestwater.2c00052Crossref Scopus (2) Google Scholar are not appropriate to use to extrapolate to non-prison populations as other sources (eg, laundry) can substantially alter these markers in prisons. Experience from 1 year of wastewater-based surveillance monitoring in UK and US prisons has shown that such surveillance provides public health officials insight with regard to infectious disease carriage and transmission between people who live in prison and prison staff, among whom rapid action could alleviate the risk of larger outbreaks. Linking people who live in prisons to communities through lead-lag analysis has shed light on factors that govern whether a prison is a reservoir or amplifier for infectious agents. Wastewater-based surveillance could be important for the protection of populations at high risk of infectious diseases and could offer long-term advances in public health surveillance after COVID-19, for example for other pathogens of high significance (eg, HIV) and antimicrobial resistance (broader wastewater-based surveillance targets). Wastewater-based surveillance could enable public health authorities to develop targeted prevention and education programmes for hygiene measures and prevention of drug use within prisons. COVID-19 remains one of the biggest global public health challenges, accounting for more than 6·2 million deaths since the beginning of the pandemic. Alternative tools for rapidly identifying, containing, and reducing the spread of SARS-CoV-2, the virus that causes COVID-19, are crucial for susceptible populations. Examples include individuals living in prisons, care homes, and hospitals, among whom infection rates and mortality are often elevated compared with the general population.1Hassard F Lundy L Singer AC Jasmine G Di Cesare M Innovation in wastewater near-source tracking for rapid identification of COVID-19 in schools.Lancet Microbe. 2020; 2: e4-e5Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Prison facilities including general prisons, juvenile detention centres, immigration detention centres, and community-rehabilitation centres represent particularly high-risk settings because individuals who are incarcerated reside in confined, densely populated, closed, and poorly ventilated conditions. In 2020, The Lancet reported that prisons "are in no way equipped to deal with COVID-19"2Burki T Prisons are "in no way equipped" to deal with COVID-19.Lancet. 2020; 395: 1411-1412Summary Full Text Full Text PDF PubMed Google Scholar and infection burdens in such settings are unknown due to paucity of testing. In the USA, more than 2700 COVID-19-related deaths have occurred in prison settings, with a mortality rate of around 200 prisoners per 100 000 population (April, 2020, to April, 2021),3Marquez N Ward JA Parish K Saloner B Dolovich S COVID-19 incidence and mortality in federal and state prisons compared with the US population, April 5, 2020, to April 3, 2021.JAMA. 2021; 326: 1865-1867Crossref PubMed Scopus (17) Google Scholar resulting in COVID-19 mortality rates 2·4–3·0-times higher than the general population.4Braithwaite I Edge C Lewer D Indirect age-and sex-standardisation of COVID-19-related mortality rates for the prison population of England and Wales.https://discovery.ucl.ac.uk/id/eprint/10123265/1/Covid19_and_prisons_SMRs.pdfDate: March 8, 2021Date accessed: May 24, 2022Google Scholar High prevalence and transmissibility of disease agents in prisons is also associated with the elevated risk profiles among individuals in the criminal justice system, such as complex medical and lifestyle histories (age, sedentary lifestyle, asthma, and obesity), high prevalence of multimorbidity, and various life-threatening conditions. Such problems are highest in prisons in low-income and middle-income settings due to substantial overcrowding, inadequate food and water availability, poor ventilation, and poor sanitation, all of which exacerbate transmission of infectious diseases between individuals living in prison. Prisons are also connected to communities (and other prisons) through prison staff and residents being infected in the community and through prisoner transfers to other facilities. In addition, infections can spread through prisoner day release, during prison receptions, and during medical care. More studies are needed to ascertain whether prisons can act as amplifiers of, or reservoirs for, COVID-19 and other infectious diseases5Barnert E Ahalt C Williams B Prisons: amplifiers of the COVID-19 pandemic hiding in plain sight.Am J Public Health. 2020; 110: 964-966Crossref PubMed Scopus (18) Google Scholar and whether prisons represent points at which interventions could be implemented to prevent wider transmission. We contend that inadequate action on managing prison health will result in further outbreaks of COVID-19 and other emerging infectious diseases that affect the health and wellbeing of staff, residents, and local populations. Wastewater-based surveillance has been widely applied during the COVID-19 pandemic as an unbiased, aggregate and anonymous method of monitoring for population-level infection trends and the spread of variants,6Wade MJ Lo Jacomo A Armenise E et al.Understanding and managing uncertainty and variability for wastewater monitoring beyond the pandemic: lessons learned from the United Kingdom national COVID-19 surveillance programmes.J Hazard Mater. 2022; 424127456Crossref PubMed Scopus (32) Google Scholar but it should not replace clinical testing for infectious diseases. Despite ethical concerns, wastewater-based surveillance of prisons has been used in numerous countries for surveillance of self-administered prescription and recreational drugs.7Postigo C de Alda ML Barceló D Evaluation of drugs of abuse use and trends in a prison through wastewater analysis.Environ Int. 2011; 37: 49-55Crossref PubMed Scopus (118) Google Scholar Our experience of wastewater-based surveillance across spatial scales (from sewershed to building to sub-building level) has enabled early identification of local outbreaks and informed targeting for rapid clinical testing, to reduce the disease burden and prevent further infections.8Alexander TY Hughes B Wolfe MK et al.Estimating relative abundance of 2 SARS-CoV-2 variants through wastewater surveillance at 2 large metropolitan sites, United States.Emerg Infect Dis. 2022; 28: 940Crossref PubMed Scopus (4) Google Scholar Three key barriers remain to fully realise the benefits of wastewater-based surveillance technology: first, paucity of data on virus faecal shedding between individuals makes it difficult to scale pathogen load to cases, and the impact of vaccines and disease variants on virus shedding warrants further research; second, determining the scope of the contributing population (eg, defecation frequency and movement of individuals between and within sewer catchments); and, third, dilution from other water sources, such as industrial scale laundries, reducing infectious disease marker signals. Prisons are unique, since residents in most prisons contribute regularly to the same wastewater stream (with the exception of day release prisoners and staff) and, therefore, provide a representative indicator of cases, such as COVID-19, when paired with clinical surveillance data. Prisons present several challenges for implementation of wastewater-based surveillance. First, access to wastewater is restricted for most research groups and prison infrastructure (eg, sewer pipes) can make installation of sampling equipment difficult. Second, individuals who live in prisons represent a marginalised population, and a strict ethical code is required for research work,9Hrudey SE Silva DS Shelley J et al.Ethics guidance for environmental scientists engaged in surveillance of wastewater for SARS-CoV-2.Environ Sci Technol. 2021; 55: 8484-8491Crossref PubMed Scopus (14) Google Scholar thus ethical review board oversight is crucial. Third, the minimum size of the population that can and should be monitored is unknown. Fourth, the nature of prisons makes their wastewater variable and some common chemical markers (eg, ammonia)10Hoar C Li Y Silverman AI Assessment of commonly measured wastewater parameters to estimate sewershed populations for use in wastewater-based epidemiology: insights into population dynamics in New York City during the COVID-19 Pandemic.ACS EST Water. 2022; (published online April 20.)https://doi.org/10.1021/acsestwater.2c00052Crossref Scopus (2) Google Scholar are not appropriate to use to extrapolate to non-prison populations as other sources (eg, laundry) can substantially alter these markers in prisons. Experience from 1 year of wastewater-based surveillance monitoring in UK and US prisons has shown that such surveillance provides public health officials insight with regard to infectious disease carriage and transmission between people who live in prison and prison staff, among whom rapid action could alleviate the risk of larger outbreaks. Linking people who live in prisons to communities through lead-lag analysis has shed light on factors that govern whether a prison is a reservoir or amplifier for infectious agents. Wastewater-based surveillance could be important for the protection of populations at high risk of infectious diseases and could offer long-term advances in public health surveillance after COVID-19, for example for other pathogens of high significance (eg, HIV) and antimicrobial resistance (broader wastewater-based surveillance targets). Wastewater-based surveillance could enable public health authorities to develop targeted prevention and education programmes for hygiene measures and prevention of drug use within prisons. MDC and DG contributed equally to writing this Comment. We declare no competing interests.